HospitalInspections.org

Based on review and interview the Governing Body failed to;

1.
ensure the right of each patient to provide informed consent to either accept or refuse psychoactive medication for 5 of 5 patients [Patient #A4, D3, D10, E2, and E4], as consents were either non-existent or the patient was documented as incapacitated. This applies to patients not ordered by a court to receive such medication.

Refer to Tag A0131

2.
A. have chemical restraints listed on the restraint log.

B. The facility failed to have a clear policy and procedure concerning mechanical restraints. The policy said mechanical restraints were prohibited but gives instruction on the use of mechanical restraints and patient assessments in mechanical restraints.

C. The facility failed to have a policy that gave a time frame on discontinuation of patient observation after the administration of a Chemical Restraint /Emergency Behavioral Medication (EBM).

D. Nursing failed to consistently monitor and document on patients that were given chemical restraints/EBM in 5 (#D3, D5, E2,E3, and E4) of 5 charts reviewed.

Refer to A0144


3.
A. ensure Patient #D3's accusations of abuse, mistreatment, and failure to investigate her request to confirm she was a physician was not investigated and delayed her discharge and treatment.

B. ensure there was a physician's order to hold the patient involuntarily while proceeding with the OPC. There was no OPC on the chart to hold the patient in the facility for 11 days in 1 of 1(D3) patient chart reviewed.

C. advocate for the patient and start a grievance procedure after multiple complaints of abuse in 1 of 1(D3) chart reviewed.

Refer to A0145

Based on review and interview the facility failed to;

1.
Based on a review of facility documentation and staff interviews, the facility failed to ensure the right of each patient to provide informed consent to either accept or refuse psychoactive medication for 5 of 5 patients [Patient #A4, D3, D10, E2, and E4], as consents were either non-existent or the patient was documented as incapacitated. This applies to patients not ordered by a court to receive such medication.

Refer to Tag A0131

2.
A. have chemical restraints listed on the restraint log.

B. The facility failed to have a clear policy and procedure concerning mechanical restraints. The policy said mechanical restraints were prohibited but gives instruction on the use of mechanical restraints and patient assessments in mechanical restraints.

C. The facility failed to have a policy that gave a time frame on discontinuation of patient observation after the administration of a Chemical Restraint /Emergency Behavioral Medication (EBM).

D. Nursing failed to consistently monitor and document on patients that were given chemical restraints/EBM in 5 (#D3, D5, E2,E3, and E4) of 5 charts reviewed.

Refer to A0144


3.
A. ensure Patient #D3's accusations of abuse, mistreatment, and failure to investigate her request to confirm she was a physician was not investigated and delayed her discharge and treatment.

B. ensure there was a physician's order to hold the patient involuntarily while proceeding with the OPC. There was no OPC on the chart to hold the patient in the facility for 11 days in 1 of 1(D3) patient chart reviewed.

C. advocate for the patient and start a grievance procedure after multiple complaints of abuse in 1 of 1(D3) chart reviewed.

Refer to Tag A0145

Based on a review of facility documentation and staff interviews, the facility failed to ensure the right of each patient to provide informed consent to either accept or refuse psychoactive medication for 5 of 5 patients [Patient #A4, D3, D10, E2, and E4], as consents were either non-existent or the patient was documented as incapacitated. This applies to patients not ordered by a court to receive such medication.

Findings were:

Facility policy entitled, "Informed Consent for Medication Administration," last reviewed 6/17/22, included the following:
"DOCUMENTATION OF INFORMED CONSENT:
Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient admitted under the voluntary, emergency, or OPC (Order for Protective Custody) provisions of Texas statutes or his legal authorized representative. This executed form will establish a rebuttal presumption of valid consent and will be retrained in the medical record ..."

A review of the facility medical record for voluntary Patient #A4, revealed he received psychoactive medication without providing appropriate consent. Lorazepam and valproic acid were prescribed and administered to the patient with no evidence of any kind that he gave consent, or even knew he was taking it. Though other psychoactive medication consents were signed by the patient on 4/22/22, the physician documented that Patient #A4 was unable to comprehend benefits and side effects at the time he signed them. Thus, none of the signed consents supported that the patient was appropriately informed and that he gave willing consent to receive these medications, which included the anti-psychotic medication Prolixin. Patient #A4 was administered doses of each of the above medications.

For example, an Intake Assessment form on 4/19/22 indicated the patient was actively endorsing visual hallucinations and delusions.

A physician progress note on 4/21/22, dictated at 6:23 a.m., included the following:
"The patient is paranoid, suspicious, with peculiar behavior ... appearing lost. The patient is a bit sedated from medications. We will monitor him and make adjustments as necessary to improve his ability to communicate and decrease sedation ..."

A physician progress note on 4/22/22, dictated at 11:23 p.m., included the following:
" ...Treatment Plan: We will begin Zyprexa Zydis 7.5 mg twice a day for psychosis and valproic acid 500 mg twice a day for mood, benztropine 1 mg twice a day for EPS (extrapyramidal syndrome). Unable to discuss assessment, treatment plan, medications, risks and benefits with patient. Patient with very poor understanding ..."

In an interview with Staff #A8 on the afternoon of 9/27/22 in her office, she confirmed the above findings, and added, "He only received Haldol as an emergency medication, but you're right about the others."



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Findings:

Patient #E2
A review of the medical record for Patient #E2 was as follows:

" ...Medication Consent for Atarax was given as a verbal consent by the patient on 9/10/2022 at 11:25 AM. No physician name was on the consent and the two witness signatures were illegible ...

Medication Consent for Zyprexa was given as a verbal consent by the patient on 9/10/2022 at 11:25 AM. No physician name was on the consent and the two witness signatures were illegible ...

Medication Consent for Zyprexa was given as a verbal consent by the patient on 9/10/2022 at 9:00 PM. The two witness signatures were illegible ...

Medication Consent for Atarax was given as a verbal consent by the patient on 9/10/2022 at 9:00 PM. The two witness signatures were illegible ...

Medication Consent for Risperdal was given as a verbal consent by the patient on 9/11/2022 at 9:15 AM ..."

A review of the physician documentation dated 9/10/2022 at 10:42 PM by Dr._____ was as follows:
" ...The patient is disorganized in her behavior and thought, unable to focus on questions answered, provided answers to questions that are tangential, lose, and illogical ..."
A physician progress not dated 9/11/2022 revealed Patient #E2 was disorganized, with delusions, paranoia, hearing and seeing things. insight and judgment are poor ..."


An interview was conducted with Staff #E2 on 9/28/2022 after 12:00 PM. Staff #E2 was asked if Patient #E2 had the capacity to understand the risks and benefits of the Psychoactive medications administered to her during her inpatient stay. Staff #E2 confirmed Patient #E2 did not have the capacity to consent for the administration of the psychoactive medications, and she also confirmed Patient #E2 was given these medications during her inpatient stay.


PATIENT #E4

Patient #E4 was involuntarily admitted to the facility on 7/21/2022 with a diagnosis of Schizoaffective Disorder. She was placed under an Order of Protective Custody on July 20, 2022. The medical record did not reveal a court order for forced medication.

A review of the document titled, "Medication Consent for Zyprexa revealed Patient #E4 gave verbal consent on 7/22/2022 at 22:15 (10:15 PM) for Zyprexa (antipsychotic medication). A review of the nursing note dated 7/22/2022 patient was only oriented X1, patient was very confused, paranoid, self-talk, and need constant redirection. There was no physician evaluation documented in the record prior to the medication being administered.

A review of the document titled, "Medication Consent for Klonopin revealed Patient #E4 gave verbal consent on 8/02/2022 at 2:00 PM. On page 2 of 2 in the blank where the patient authorizes and directs the physician to provide treatment with the medication, the physician's name was left blank. A review of the nursing note dated 8/02/2022 at 2:00 PM was as follows; " ...Pt is noticeable disorganized and confused. Thought process is illogical ..."

A review of the document titled, "Medication Consent for Clozapine revealed Patient #E4 gave verbal consent on 8/10/2022 at 7:00 PM. A review of the nursing note dated 8/10/2022 at 21:00 (9:00 PM) was as follows; " ...Pt appears confused. Unable to assess ..."

An interview was conducted with Physician #E3 on 9/29/2022 after 9:00 AM. Physician #E3 was asked if he explained the risks and benefits of the medications Klonopin, Clozapine, and Zyprexa to the patient before the consent was signed. Physician #E3 stated, "No, this patient did not have the ability to understand any of that until right before she was discharge. Then she started cheek (not swallow) her medications and I had to tell the nurses to watch for that. Eventually I had to start giving her injections to get her therapeutic and ready for discharge. She finally got better but she was a tough one."

A review of the Medication Administration Record (MAR) confirmed Patient #E4 was administered doses of each of the medications.

Physician #E3 and Staff #E2 confirmed that Patient #E4 did not have capacity to understand why the medications were being administered to her or the risks and benefits of receiving them and.

Staff #E2 confirmed that Patient #E4 did not have the capacity to consent to the medications.



32143

Findings;

Review of Patient #D3's medication consents revealed she signed Atarax (Antihistamine) and Wellbutrin (Antidepressant). Review of the medication consent for Seroquel (Antipsychotic) was not signed and the nurse wrote "pt gives verbal consent." The consent was signed by two nurses and signed on 5/31/21. The patient refused to take the Seroquel while hospitalized and in her written complaint stated that she refused to sign the consent for Seroquel.

Review of Patient #D10's psychiatric evaluation dated 9/25/22 revealed the patient was "oriented to person only. She does not know why she is the hospital. She does not know the name of the hospital. She does not know today's date. Judgement and insight both seemed to be impaired at this time. Review of the patients medication consents revealed one for Zyprexa (antipsychotic) and for Depakote (anticonvulsant). The nurse documented that the patient gave verbal consent and two nurses signed. There was no evidence or documentation that the patient had the capacity to consent or understood her rights to refuse medications and how to make a formal complaint.

Based on review and interview the facility failed to have chemical restraints listed on the restraint log.
A. The facility failed to have a clear policy and procedure concerning mechanical restraints. The policy said mechanical restraints were prohibited but gives instruction on the use of mechanical restraints and patient assessments in mechanical restraints.

B. The facility failed to have a policy that gave a time frame on discontinuation of patient observation after the administration of a Chemical Restraint /Emergency Behavioral Medication (EBM).

C. Nursing failed to consistently monitor and document on patients that were given chemical restraints/EBM in 5 (#D3, D5, E2,E3, and E4) of 5 charts reviewed.


Review of the patient restraint log revealed there was no chemical restraints/EBM listed. Staff #D3 confirmed the chemical restraints/EBM were not listed on 9/26/22. Staff #D3 confirmed the restraint log only had holds or seclusions. Staff #D3 confirmed the facility uses no mechanical restraints.

Patient #D5

Review of Patient #D5 revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her chart. The order was dated 9/15/22 at 1350. The order was for Haldol 10mg IM, Benadryl 50mg IM, and Ativan 2 mg IM. The nurse had written, "pt pushing staff and another pt and another pt fell on the floor. Pt screaming and hitting wall. Pt pushed the nurse at the nurse's station and in her room." The nurse documented on the order that po medication was attempted but did not document the time or date the medication was administered.

Review of the restraint packet revealed a Face-to-Face form. The nurse documented that the face to face was performed at 1420 on 9/15/22 (30 minutes after the medication was administered). The nurse failed to document if pain or discomfort was assessed. The nurse documented that the patient refused vital signs. Nurse documented respiratory status was within normal limits, but no respirations were documented. The nurse documented that based on system review, behavioral assessment, review of recent lab results, medical history, medication regimen, drug history, or any factors contributing to the patient violent or self-destructive behavior that there was "no" contributing factors. However, the nurses note dated 9/15/22 7am to 7pm stated, ..." pt requesting nicotine patch because she states MHT did not let her go smoke. Dr.___ notified and new order for nicotine patch x 1 dose. ...pt requested a 4 hr letter but explained to pt she is involuntary. Pt started to scream and very loudly at the nurse's station. Pt almost hit me in front of the nursing station ..." The nurse documented in the note she gave medication at 1400 but the face to face said 1350. The documentation showed inconsistency between the administration times and possible reasons patient was having an emergency behavioral incident.

Review of the nurses' notes revealed there was no other assessment performed on the patient other than the face to face at 1420. The 7:00PM shift documented at 2230 but there was no mention of behaviors or medication assessment.

Review of the nursing treatment plan revealed the nurse checked "Nursing will assign 1:1 observation for duration of seclusion or restraint intervention." There was no 1:1 ordered and no 1:1 observation documented.

Review of the policy and procedure, "Use and Monitoring of Physical Restraint, Emergency Medications, and Seclusion Policy" date issued 8/27/2020 and last reviewed 5/17/22 talks about physical escorts, manual holds, seclusion, but stated that mechanical restraints are prohibited.

Review of the policy stated, "Medication/Chemical Restraint: The administration of a medication for the purpose of controlling an acute episodic behavior, with the intent to restrict the patient's functioning or movement and/or to bring about sedation.

Texas Administrative Code definition: Chemical Restraint is the use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition. The use of chemical restraints in the state of Texas is not allowed.

Emergency Medication: Psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric/behavioral emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. A behavioral emergency is defined as a situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive, de-escalative, or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain or seclude the individual to prevent imminent harm to self or others.

The use of emergency medications will be documented in same manner as physical/mechanical restraint and seclusion.
...4.5 The patient shall be assessed every 15 minutes while in restraint/ seclusion by the RN/assigned trained staff. The selection of an intervention and determination of the frequency of assessment and monitoring needs to take into consideration the patient's condition, cognitive status, and risks associated with the use of the chosen intervention. The assessment includes:
4.6.1 Signs of any injury associated with the use of restraint/seclusion.
4.6.2 Circulation and skin integrity
4.6.3 Mental status
4.6.4 Level of distress and agitation
4.6.5 Readiness for discontinuation of restraint/seclusion.

...3.5 The RN must assess the effectiveness of the emergency medication 30 minutes after administration."

The policy stated mechanical restraints were prohibited but stated in this paragraph to document in the same manner as a physical/mechanical restraint, and seclusion. (page 3 of 19) The policy was unclear and gave conflicting instructions. There was no defined instruction for behavioral EBM assessment and monitoring. An EBM cannot be discontinued unlike a seclusion or physical restraint. Physical restraints and EBM restraints are not the same. The nurse needs physician instruction on the length of time to observe the patient after EBM was administered.


Patient #D3

Review of Patient #D3 nurses notes dated 5/28/21 at 10:45am revealed the nurse documented the "pt obsessed paranoid, delusional, oppositional, bizarre behavior, attempted to attack staff/peers, yelling, verbally aggressive, manic and difficult to redirect. Pt refused scheduled antipsychotic med and refused v/s with MHT. Nurse was able to do v/s B/P 189/88, HR 74, and pt received B/P med prior to psychosis episode. Dr.___ (Physician/Staff #D13) notified and ordered Zyprexa 5 mg IM, Benadryl 25mg IM, and Ativan 1 mg IM given to pt as ordered. And pt transferred to unit 5 per Dr. ____ (Physician/Staff #D13) order. Pt was held for 1 minute to give the IM, well tolerated."

There was no documentation on what behaviors the patient was doing to be called "obsessed, paranoid, delusional, oppositional, bizarre behavior." The nurse documented only adjective words with no definition of the behaviors displayed by the patient.

Patient # D3 was administered a chemical restraint/ EBM on 5/28/21 at 10:23AM. Review of the Seclusion Restraint/Emergency Medication Order form revealed a verbal physician order was given for Zyprexa 5 mg IM, Ativan 1 mg IM, and Benadryl 25mg IM. The order was marked, "imminent danger to self and others." There was no description on how the patient was in danger to self and others.

Review of the Face-to-Face evaluation revealed it was performed on 5/28/21 at 10:55AM (35 minutes later). The nurse documented that the patient was calmer and able to communicate. Vital signs were documented but the B/P reading was marked over and illegible. There were no 15-minute assessments found to monitor the patient after given a restraint. There were no vital signs documented again until 5/28/21 at 7:59PM. Review of the "all observations record during stay" dated 5/28/22 at 11:26AM revealed the nurse documented that the Benadryl and Ativan was "tolerated." The nurse did not document on the Zyprexa until 5/28/21 at 1:21PM (2 hours later) even though the medications were given all at the same time.

An interview was conducted on 9/26/22 with Staff #D9. Staff #D9 was asked after administering a chemical restraint/EBM to a patient when do you go back to assess the patient, how frequently and for how long? Staff #D9 stated she had administered a chemical/ EBM restraint that morning to a patient. Staff #D9 stated she checks on them a few minutes after she gives them the medication, but the assessment is done when the face to face is done. Staff #D9 confirmed that was the nursing assessment and the face to face and that the face to face can be done anytime within 1 hour of the administration of a restraint. Review of Patient #D6 revealed she had an order for a Zyprexa IM on 9/26/22 at 11:42. At 2:00PM there was still no documentation of the restraint or assessments. Staff #D9 confirmed that she had not written any assessments on the patient (Patient #D6) and was unable to provide the face to face.

An interview was conducted on the afternoon of 9/28/22 with Staff #D18, #D19, and #D20. Staff #D18 was asked after administering a chemical restraint/EBM to a patient when do you go back to assess the patient, how frequently, and for how long? Staff #D18 stated, "in 30 minutes. I see the patient, check vitals, ask questions. After that I check them every hour then every 4 hours." Staff #D18 stated she just uses her nursing judgement on when to stop assessing the patient after a restraint.

Staff #D19 stated, "every 30 minutes for 4 hours. I take a couple of vital signs until I think they are stable. I try to follow the packet."

Staff #D20 observed all the interviews and confirmed that there was an issue with all the different comments. Staff #D20 stated that this would have to be changed at the corporate level but she was aware there was a problem with the policy and the understanding of the staff.


An interview was conducted with Staff #D3 and #D4 on 9/28/22. Staff #D4 was asked if there was any grievances or incident reports for Patient #D3? Staff #D4 stated that she had looked and there was no incident reports found for Patient #D3 throughout her stay. Staff #D3 stated that the facility had another individual in place as the risk manager but was no longer there. Staff #D3 stated that was a problem in the past in getting those incident reports done and reviewed by the Risk Manager. The facility was unable to provide any incident reports or grievances concerning Patient #D3.

Staff #D3 stated that they were monitoring all restraints and was part of their plan of correction. Staff #D3 was shown that there was no process in how the RN was to assess a chemical restraint vs a physical restraint. Staff #D3 stated the nurse was to monitor the patient at the same frequency as the physical restraints. The policy stated to monitor restraints q (every)15 minutes until the "physical" restraint ended. Staff #D3 could not tell me how long the nurse was to continue to monitor the patient after a chemical restraint/ EBM was administered. Staff #D3 was informed that interviews had been done by the surveyors with nursing staff and they all gave different interpretations on how to observe, assess and document concerning the administration of chemical/EBM restraints.

Staff #D4 stated that she was relatively new to this position at the facility but had experience as a Risk Manager (RM). Staff #D4 stated that she had a monitoring tool and was monitoring the restraint process. Staff #D4 supplied the surveyor with copies of chart monitoring forms for restraints. Review of the form revealed there was a monitor indicator for "Supervision of intervention/assessment of patient by an RN." All the monitoring sheets that were provided were reviewed in August of 2022. Review of the following monitoring tools revealed:

Patient #D11 Emergency Medications were administered. Haldol, Ativan, and Benadryl. "Rn administered IM medications and assessed pt. multiple times afterward." There was no documentation on how frequently or when the nurse chose to stop assessing the patient.

Patient #D12 IM medications were administered. Under intervention and assessment, the RM documented, "RN on site during all interventions." There was no monitoring on the q 15-minute assessments or when the assessments were completed.

Patient #D13 Pt was administered emergency medications, but the tool does not specify oral or IM. Under supervision and assessment, the RM documented, "RN administered emergency medication IM and is assessed afterwards. Patient is placed into seclusion and is monitored by the MHT continuously, while the RN is seen assessing patient 4x during seclusion." There was no documentation that the patient was being assessed appropriately for the chemical restraint and not just seclusion.

Patient #D14 was administered EBM. Under assessment the RM documented, "RN administered the IM medications with a second RN observing." There was no documentation that the nurse monitored the patient appropriately after the chemical/ EBM restraint.

Patient #D15 received two chemical/EBM restraints. The sheet stated on 8/20/22 the patient received IM Medications shortly after the patient was placed in seclusion. On assessment the RM documented, "Unit RN on site throughout all restrictive interventions. Post intervention face to face evaluation completed within one hour requirement." The face to face has an area for the RN assessment and vital signs but that was only one assessment. On 8/21/22 the patient received a chemical restraint/EBM under assessment the RM documented, "RN administered medication, but this could not be located on camera." There was no documentation that the RM reviewed the chart to see if assessments were done q 15 minutes by the nurse and for how long.

Patient #D16 RM documented, "Emergency medication applied in patient room and off camera." Under assessment, "Emergency medication administration supervised by multiple RN."

During the interview that was conducted with Staff #D4 on 9/28/22. Staff #D4 revealed that she was not a nurse or physician and was reviewing the restraints via video tape and by the chart. Staff #D4 stated that she was looking at the face to face to see if it was completed in the 1-hour time frame and was completed. Staff #D4 was not aware of the policy and procedure that stated q 15-minute checks. Staff #D4 confirmed she did not know how long nursing was to monitor the patient that received a chemical restraint/EBM.















40989

Findings:

PATIENT #E2

9/08/2022

Review of the record revealed an Intake Nursing Assessment for admission was completed on 9/08/2022 at 9:45 AM.

A review of Patient #E2's record revealed she was admitted to the facility on 9/08/2022 at 12:00 PM. The record revealed Patient #E2 had a "Seclusion/Restraint/Emergency Medication Order" on her chart. The telephone order from Physician #E8 was dated 9/08/2022 at 15:55 (3:55 PM). The medication order was for Benadryl 50mg IM (intramuscular), Ativan 2mg IM, and Haldol 5mg IM. As of 9/28/2022 the telephone order had not been signed by the Physician. The medication was administered at 16:10 (4:10 PM). The nurse documented, "increase psychosis, increase agitation, running the hallway naked, jumping on staff, difficult to verbally redirect patient."

A review of the Restraint Packet dated 9/08/2022 revealed the Post Intervention Face to Face (an assessment to be completed within 1 hour of initiation of intervention) was initiated at 17:40 (5:40 PM). This was 1 hour and 30 minutes after the emergency medication was given. The nurse documented the medication as "effective and the patient is calmer but with poor insight." The nurse documented the respiratory status was within normal limits, but no respirations were documented. The nurse also documented Patient #E2 refused vital signs. The nurse had documented "Non-Emergency Medication ordered. Zyprexa 10mg PO (oral) PRN increase psychosis/agitation." There was no date or time documented when the medication was given or refused by the patient.

A review of the Nursing Admission Assessment (nursing assessment completed when the patient arrives on the specific unit) was not signed, dated, or timed. Further review of the nurses' notes revealed there was no other assessment performed on the patient after the face to face at 5:40 PM on 9/08/2022 until 4:00 AM on 9/09/2022.

9/15/2022
A review of the Seclusion/Restraint/Emergency Medication Order document revealed the patient received an IM injection of Benadryl 50mg, Ativan 2mg, and Haldol 5mg on 9/15/2022 at 12:20 AM. The nurse documented, "Increase psychosis, increase agitation, fighting another patient, running towards the male section of the unit. Difficult to verbally redirect."

A review of the Restraint Packet dated 9/15/2022 revealed the Post Intervention Face to Face was initiated at 01:15 AM. The nurse documented the medication was effective and "Pt (patient) is sitting in the hallway, calmer. Pt tolerated well, Pt irritable." The nurse documented the vital signs. Further review revealed the Intake Nursing assessment was completed on 9/08/2022 at 9:45 AM.
Review of the nurses' notes revealed there was no other assessment performed on the patient other than the face to face at 1:15 AM on 9/15/2022 until 9:00 AM on 9/15/2022.

PATIENT #E3

9/21/2022
A review of Patient #E3's record revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her record. The order was dated 9/21/2022 at 12:00 PM. The order was for Zyprexa 10mg IM and Benadryl 50mg IM. The nurse had written, "threatening to hit staff, increased verbal and physical aggression, poured water on staff, attempted to fight with staff."

Review of the restraint packet revealed a Face-to-Face was documented on 9/20/2022 at 12:45 PM. The nurse documented that the patient refused vital signs. The nurse documented Circulatory Status was WNL (within normal limits), pulses present in all extremities, but no pulse rate was documented, Skin warm and dry, respiratory status was within normal limits, but no respirations were documented.

9/22/2022
A review of Patient #E3's record revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her record. The order was dated 9/22/2022 at 8:20 AM. The order was for Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM. The nurse had written, "Pt attacked another patient in the milieu, punch MHT to left forehead and punched RN while attempt to redirect her." The nurse documented on the order that oral medications were attempted but did not document the time or date the medication was administered.



Review of the restraint packet revealed a Face-to-Face was documented on 9/22/2022 at 8:50 AM. The nurse documented that the patient refused vital signs. The nurse documented Circulatory Status was WNL (within normal limits), pulses present in all extremities, but no pulse rate was documented, Skin warm and dry, respiratory status was within normal limits, but no respirations were documented.

Review of the nurses' notes revealed there was no other assessment performed on the patient other than the face to face at 8:50 AM on 9/22/2022. The patient was discharged AMA (against medical advice) on 9/22/2022 at 3:30 PM.


PATIENT #E4

8/01/2022
A review of Patient #E4's record revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her record. The order was dated 8/01/2022 at 3:25 AM. The order was for Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM. The nurse had written, "Pt hitting staff, throwing fists at staff, pulled a staff by the back (illegible wording) at the monitor screen, verbally aggressive and difficult to redirect." The nurse documented on the order that oral medications were attempted but did not document the time or date the medication was administered.


Review of the restraint packet revealed a Face-to-Face was documented on 8/01/2022 at 3:55 AM. The nurse documented that the patient refused vital signs. The nurse documented the medication was effective. The nurse also documented the "patient tolerated well, patient currently asleep." The nurse documented Circulatory Status was WNL (within normal limits), pulses present in all extremities, but no pulse rate was documented, Skin warm and dry, Patient denied any pain, respiratory status was within normal limits, but no respirations were documented. The nurse documented, "patient currently asleep does not want to cooperate with vitals or assessment."

Review of the nurses' notes revealed there was no other assessment performed on the patient other than the face to face until 11:30 AM on 8/01/2022.

8/01/2022
A review of Patient #E4's record revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her record. The order was dated 8/01/2022 at 19:00 (7:00 PM). The order was for Ativan 1mg IM, Haldol 10mg IM, and Benadryl 50mg IM X1 Now. The nurse had written, "Patient was hitting and pulling staff member, was also verbally aggressive and difficult to redirect." The emergency medication ordered for a now dose was not given until 20:55 (8:55 PM). The nurse documented on the order that non-emergency medications were refused by the patient.

An order written by Physician #E10 on 8/01/2022 read "Transfer to Unit #5" the time of the order was illegible.

Review of the restraint packet revealed a Face-to-Face was documented on 8/01/2022 at 8:55 PM. The Nurse documented, "patient was transferred to unit 5 per MD's order. Patient tolerate (sic) med well, in unit 5 at present moment fast asleep." Patient refused vital signs. The nurse documented the medication was effective. The nurse documented Circulatory Status was WNL (within normal limits), pulses present in all extremities, but no pulse rate was documented, Skin warm and dry, cold and clammy, Patient denied any pain, respiratory status was within normal limits, but no respirations were documented.

The nursing documentation did not explain why a "Now" order given by the physician for a behavioral emergency was not administered for 1 hour and 55 minutes after the order was received.

A nursing assessment was documented at 11:30 AM on 8/01/2022 during the 7AM-7PM shift. A nursing assessment was documented on the 7PM-7AM shift but there was no specific time.

During an interview on the afternoon of 9/28/2022, Staff #E2 was unable to give specific a time the assessment was completed. Staff ##2 confirmed that a specific time of the assessment should have been documented.


8/08/2022
A review of Patient #E4's record revealed she had a "Seclusion/Restraint/Emergency Medication Order" on her record. The order was dated 8/08/2022 at 22:28 (10:28 PM). The order was for Ativan 1mg IM Stat. Now. The nurse had written, "Patient was hitting herself on the floor, was also verbally aggressive and difficult to redirect." The nurse documented on the order that non-emergency medications were refused by the patient.

Review of the restraint packet revealed a Face-to-Face was documented on 8/08/2022 at 10:48 PM. The Nurse documented, "calmer and redirectable." Patient refused vital signs. The nurse documented the medication was effective. The nurse documented Circulatory Status was WNL (within normal limits), pulses present in all extremities, but no pulse rate was documented, Skin warm and dry, Patient denied any pain, respiratory status was within normal limits, but no respirations were documented. The nurse documented, "Right wrist swollen from previous, MD aware."

A review of the nurse's notes revealed there was no other assessment performed on the patient after the face to face was completed at 10:48 PM until 8/09/2022 at 1:00 AM.


An interview was conducted with Staff #E2 was conducted on 928/2022 after 12:00 PM. Staff #E2 was asked what the policy was for reassessment of a patient after a chemical restraint was initiated. Staff #E2 stated, "We do not do chemical restraints at this facility." Staff #2 was given an alternate explanation of a chemical restraint and was then asked what the policy was for reassessment after an emergency behavioral medication was given for a behavioral emergency. Staff #E2 stated, "We do the face to face and document on the restraint packet." Staff #E2 confirmed there was no specific guidelines in the restraint policy on when to assess the patient, what was required for the assessment, and how long the patient must be monitored after emergency medications were administered." Staff #E2 confirmed the facility does not use mechanical restraints and the restraint policy has no clear guidance for nursing on how to monitor the patient after an EBM was administered.


Staff #E2, and Staff #E11 confirmed the findings.

.
The facility failed to;

A. ensure Patient #3's accusations of abuse, mistreatment, and failure to investigate her request to confirm she was a physician was not investigated and delayed her discharge and treatment.

B. ensure there was a physician's order to hold the patient involuntarily while proceeding with the OPEC. There was no OPEC on the chart to hold the patient in the facility for 11 days in 1 of 1(D 3) patient chart reviewed.

AC. advocate for the patient and start a grievance procedure after multiple complaints of abuse in 1 of 1(D 3) chart reviewed.

Patient #D 3 was a 62-year-old female that presented to the facility with aggression and agitation. Patient #D 3 was admitted to the facility on 5/24/21.

Review of the Psychiatric Evaluation performed by Staff #D 13 dated 5/25/21 stated, "CHIEF COMPLAINT: ''I have a lot of anxiety over the divorce."

HISTORY OF PRESENT ILLNESS: This is a 62-year-old Caucasian female, presented on DEW due to worsening of bizarre behavior at the church. Patient became erratic and began yelling in the middle of the services. Patient was taken into the church conference room Patient informed the police that she did not want men around her. When asked to leave the property, patient became aggressive, and she continued to escalate her situation. Patient threw a gun (SIC) at the officers (The patient threw GUM from the police report). Patient exhibited nonsensical speech. Patient informed officers to call her "Dr. ______." Patient continued to throw herself on the floor during the initial contact with the police. Patient displayed increased resistance and combativeness with police officers. Later, after patient was taken for assessment, patient denies having auditory or visual hallucinations. She denies having any suicidal or homicidal ideation's. Patient endorses homicidal ideation's towards church staff and police officers. Patient also endorses grandiose and religious delusions. Patient reports no sleep problem and decreased appetite. During the initial assessment, patient was minimizing her behavior and kept saying that there is misunderstanding, and she kept saying, ''It was blown out of proportion." Patient continued to present with very poor insight throughout this assessment. Today, patient states, ''I was at the church. Police called from the church on Sunday because I was supposed to speak to the pastor, my husband wanted to divorce me, then they called the police. Police twisted my shoulder and I have bruises on me." Patient has complained of having severe anxiety for the past 3 months since her husband asked her for divorce. Patient stated that she has not been sleeping and has been crying. Patient continues to refer herself as Dr. ______. Patient states, ''I'm a physician. I'm doing online training for wound care, and I finished my residency in 1993 and I quit my job 7 weeks ago. ...This is likely her first inpatient psychiatric admission ...Patient is extremely delusional and preoccupied and said she is a doctor. She continues to have grandiose delusions ... Patient is oriented to person, place, and time.

Review of the chart revealed the facility's court liaison Staff #D 22 made application for an Order of Protective Custody (OPC). The certificate of medical examination done by the psychiatrist was in the chart and where the application was filed. There was no judge's order on the chart or any indication if the OPC was approved or for how long. There was no found proof that the patient was being held legally.

5/24/22
Review of the physician orders date 5/24/22 revealed there was a telephone order obtained by the nurse to hold the patient involuntary. There was no order found on the chart, by the physician, to hold the patient involuntarily while proceeding with the OPC.

5/25/22
Review of the nurses' notes dated 5/25/22 7AM -7pm shift stated patient was coherent, cooperative/calm and impulsive but there was no documentation on what the patient was doing to be "impulsive." The nurse wrote in her progress note that the patient had no behavioral problems.

Review of the medication MAR reveled the patient had taken her medication for hypertension but had refused the Seroquel (antipsychotic medication).

Review of form titled "Primary Psychiatric Tx Plan Problem" Revealed the nurse documented Schizoaffective /Bipolar. There was no documentation found that the patient was ever diagnosed by a psychiatrist as Schizoaffective. The nurse documented that the patient was medication compliant, but the Medication Administration Record (MAR) stated she was refusing medications. The nurse documented that the patient stated she was sad because she was going through a divorce, and she didn't want to talk about it. The nurse stated that she was "cooperative with staff. No aggression /agitation. Pt has delusions and very grandiose call herself "a doctor". Wants meds at "certain times." The nurse documented that the patient plays down what happened that brought her to the hospital. Stated that she had an "anxiety attack" and "nothing else it was no big deal."

5/26/21
Review of nurses note dated 5/26/21 at 4:45AM stated, "Pt is delusional, though cooperative and engages with staff/peers. Pt can be grandiose yesterday on OB/GYN doctor, today wound care specialist. ... had refused Seroquel at 2100 states, "My patients tell me that they have hallucinations when they take Seroquel."

Review of the chart on 5/26/21 at 11:00AM the patient was allowed to sign a consent for voluntary psychiatric admission. The patient was then allowed to request release from voluntary admission (4-hour discharge notice). The patient filled out an Against Medical Advice (AMA) questionnaire. The patient stated ... "I am not a threat to myself or others ...I seemed to be coerced to voluntarily commit myself without proper explanation or options ..."

Review of the Nurses note dated 5/26/21 revealed the nurse documented, "11:30AM ___ (Pt. #D3) has requested a 4 hr letter stating she was coerced into signing herself in. MD, nurse spvsr, CNO notified. 1315 MD will hold patient for possible commitment. Nurse spvsr and CNO aware. "There was no physician order to hold the patient for further commitment process.

Review of the physician progress note dated 5/26/21 at 1547 revealed Patient #D3 was seen via telemedicine. Stated that the patient was delusional ...talking about being a doctor and caring for her patients. Husband left home a week ago "though he was cheating on me." The physician documented, "signed 4 hr letter earlier. Poor insight still very delusional, very psychotic ... will commit pt to establish a safety plan ... Change Seroquel." There was no documentation noted that described any behaviors that made patient unsafe, delusional, or psychotic other than she claims to be a medical doctor. The psychiatrist did not document that the patient was refusing Seroquel each time.

5/27/21
Patient #D3 requested and filled out a "Request for change of Physician" form on 5/27/21 at 9:55AM. She requested two different physicians. The nurse documented on the form that one of the psychiatrists had agreed to take the patient at 10:53 AM.

Review of a complaint form dated 5/27/21 at 11:15AM revealed Patient #D3 had made a complaint to the Staff #D22 the patient advocate. Patient #D3 stated that she was upset that her current psychiatrist "was wrong to determine that I am to be committed after only speaking to me for 30 min. He only knows 5% of my story. She (the advocate) responded "you have a right to your opinion." I stated that he is a disgrace to the medical community. She stated I had a right to my opinion ... ____ (Staff #D22) is clearly not an advocate for me but rather an advocate for the doctors and the hospital." Review of the advocates response revealed it was not dated or timed. She checked a box that she met with the patient and stated, "Spoke with pt. explained the process wasn't what she wanted to hear. Became loud and rude." There was no grievance found for this complaint. The complaint was not passed on to the PI Director or Administrator for resolution.

Review of another complaint form filled out by Patient #D3 on 5/27/21 at 3:40PM revealed the patient was revoking her voluntary commitment. Stated she had spoke to an attorney and will not speak to a second physician. "I have been rail roaded and coerced into signing forms." Review of the patient advocate response that had no date or time, "spoke with pt pt sign in voluntary then decided she wanted to leave signed 4 hr letter." The advocate did not document if she met with the patient or not. There was no grievance process found or offered from administration. The surveyor was unable to speak with the advocate due to no longer employed at the facility.

Review of the physician progress note dated 5/27/21 at 1632 revealed the patient was seen by telemed. Physician documented, "Angry, very belligerent and sarcastic, hostile behavior. Refused to answer questions. Manic /delusional. Change Seroquel to 50 mg po hs to decrease mania/delusional (sic)." The physician never documented what made the patient delusional or manic. The patient had refused the Seroquel since admission. He continued to change the orders even though it was documented she had refused the medication.

5/28/21
Review of Patient #D3 nurses notes dated 5/28/21 at 10:45am revealed the nurse documented, "pt obsessed paranoid, delusional, oppositional, bizarre behavior, attempted to attack staff/peers, yelling, verbally aggressive, manic and difficult to redirect. Pt refused scheduled antipsychotic med and refused v/s with MHT. Nurse was able to do v/s B/P 189/88, HR 74, and pt received B/P med prior to psychosis episode. Dr.___ (Physician/Staff #D13) notified and ordered Zyprexa 5 mg IM, Benadryl 25mg IM, and Ativan 1 mg IM given to pt as ordered. And pt transferred to unit 5 per Dr. ____ (Physician/Staff #D13) order. Pt was held for 1 minute to give the IM, well tolerated."

There was no documentation on what behaviors the patient was doing to be called "obsessed, paranoid, delusional, oppositional, bizarre behavior." The nurse documented only adjective words with no definition of the behaviors displayed by the patient.

Patient # D3 was administered a chemical restraint/ EBM on 5/28/21 at 10:23AM. Review of the Seclusion Restraint/Emergency Medication Order form revealed a verbal physician order was given for Zyprexa 5 mg IM, Ativan 1 mg IM, and Benadryl 25mg IM. The order was marked, "imminent danger to self and others." There was no description on how the patient was in danger to self and others.

Review of the physician progress notes dated 5/28/21 at (time illegible) stated seen by telemed. The physician documented, " Impulsive, aggressive. I will sue you because pt was sent to PICU. You want to just use my insurance. Very psychotic this am trying to attack staff, yelling, and delusional. Needed IM PRN to decrease her psychosis aggression and combative behavior. Add Seroquel 25 mg po q am noon to decrease agitation." The psychiatrist failed to document how the patient was delusional and never documented a discussion with the patient concerning her commitment, failure to have a grievance documented, or her unwillingness to take any of the medication he continues to change.

5/29/21
Review of the physician progress notes for 5/29/21 stated, "Rambling about working as an MD ...illegible. Still delusional accusing her husband of cheating on her. ...Rambles non stop. Add Zyprexa, Zydis, and Ativan as prn to decrease break through mania." There was no description of delusions other than the patient is a physician. There was no documentation that the physician or any other person at the facility spoke to the patient and attempted to call her husband and include him in the process.

5/30/21
Review of the physician progress notes for 5/30/21 stated, "seen via telemed. The patient stated, "you need to google me. I am Dr _______ I did private practice for 12 yrs ... Keep rambling about her residency in Surgery ...treatment resistant manic and delusional."

5/31/21
Review of the physician progress notes for 5/31/21 stated, "seen via telemed. Rambles non stop. Still delusional." No documentation on what delusions the patient is having other than being a physician.

6/1/21
Review of the physician progress notes for 6/1/21 stated, "seen via telemed. "I did general surgery for 2 yrs and OB/GYN for 4. My husband is filing for divorce today at 4:30 more calm."

6/2/21
Review of the physician progress notes for 6/2/21 stated, "seen via telemed. "MD looked up pts name at Texas Medical Board. She is MD is not delusional about her claims as M.D. (illegible word) improved no sign of manic (illegible word). Cont. with medications. Depakote level tomorrow." Pt was held for a Depakote blood test in the am but refused all Depakote medications while in the facility. There was no documentation that the physician was aware.

6/3/21
Review of the chart revealed the patient was discharged the next day on 6/3/21. Review of the Physician Discharge Summary 8/26/21 (83) days later stated, " ... Depakote level not detected." (Patient refused all Depakote) ... "A family session was recommended during the patients stay" (there was no found documentation that the patient was offered any family therapy). " ...Patient's mood was more reactive, and affect was brighter. Patient could contract for safety and the importance of continuation of care in the outpatient setting was discussed." (There was no found documentation that the psychiatrist discussed continuation of care in the outpatient setting or that the patient contracted for safety) " ...The patient was then discharged home. The patient is treatment complaint and has improved insight into their illness. Impulse control is fair. Patient is less impulsive and can make reasonable and rational decisions."

An interview was conducted with Staff #D3 and D4 on 9/27/22. Staff #D3 stated that he did not recognize this complaint and had no incident reports or grievances on this patient but did supply the surveyor with 3 complaint forms. Staff #D3 did confirm Staff #D22 was no longer employed at the facility. Staff #D4 stated that she did not have any occurrence reports that she was aware of on Patient #D3.

Based on observation and interview the facility failed to maintain a clean and sanitary environment to mitigate the spread of infectious diseases on 3 (Unit #4, #5 and #7) of 5 units.

Findings include:

UNIT #4-GERIATRIC UNIT

An observation tour was conducted on 9/26/2022 at 11:44 AM with Staff #E1. This was an 18-bed unit and at the time of the tour the unit was full. The following was observed.

Room #402 A&B
The wooden door was chipped and exposing the porous surface underneath. The metal plate on the door frame was partially covered with a hard tan colored putty. The surface of the door was not sealed and could not be sanitized to control the spread of infectious diseases. The floor in the restroom was visibly soiled with dirt, dust, and toilet tissue.

Patient Room #404 A&B
The shower floor in the restroom was retaining water and not draining. This could lead to bacterial growth and place all patients at risk in this room of acquiring a bacterial infection. The caulk that sealed the toilet cover to the wall was peeled away from the wall and chipping paint was noted. Under the bowel of the toilet a brown dirty spot was noted. Under the sink the wall was dirty with a brown colored stain. The floor under the sink was also dirty.

Medication Room
This room is used to prepare and pass medications to patients on this Unit. On top of the automated medication dispensing cabinet, multiple pieces of old tape were seen. On the front of the cabinet right above the first row of drawers, rust was noted. Rust cannot be sanitized. Behind and under the medication dispensing cabinet was dirt, dust, trash, and old used medication cups.

ADA Shower Room #236
This room was used for disabled patients in need of a larger restroom and shower. Upon entering the room, a mop attached to a long handle was being stored in the corner. A large black area rug placed under the toilet was heavily soiled with dirt, dust, and debris. A large rolling trash can filled with trash was placed alongside the wall in this room.

Seclusion Room #239
Inside the seclusion room restroom, the toilet was noted to have toilet tissue inside the bowl. The base of the toilet was heavily soiled with dirt and dust. The paper sack next to the toilet used for trash was half full. There was toilet tissue on the floor under the sink.

UNIT #7-ADOLESCENT UNIT

An observation tour with Staff #E1 was conducted on 9/26/2022 at 2:30 PM. This was a 22-bed unit and at the time of the tour the unit had 18 patients. There are 2 medication rooms on the unit. One is at the front of the unit and one is at the back of the unit. The following was observed.

Medication Room at the end of the hall
This room was used to store and prepare medications for patients. The sink was visibly soiled with green stains around the faucet and hot and cold handles. Behind the sink the wall dirty with brown spots. The caulk was stained with a brown color. There was no splash guard near the sink and patients medications were stored on top of the counter on both sides of the sink. The patient medications were at risk of having contaminated water splashed on them during hand washing. To the left of the sink one (1) blue bin was noted storing patients medications. Medication (Midol) was on the floor in front of the biohazard bins. The medication used to store medications for patients was soiled with dirt, dust, and debris. A closed window that was opened only when passing patient medications was dirty and missing paint exposing the metal surface. At the top of the window there were brown spots that resembled rust. The wall directly above the window was soiled with brown a brown colored stain.

Patient Room #702 A&B
The wall between the two beds was missing paint exposing the sheetrock The metal covering over the air conditioner unit was soiled with dirt and dust. The floor was dirty with dust and trash. Patient #E5 confirmed that this room had been cleaned by the housekeeping staff.

Medication Room at the front of the hallwayt
Around the sink handles and the faucet was a rust-colored stain. Behind the sink, the caulk was dirty and brown in color.

During an interview in the afternoon on 9/26/2022, Staff #E4 and Staff #E5 confirmed the findings on Unit #7. Staff #E4 stated, "Sometimes these teens get out of control, and it is all we can do to keep them focused on their treatments. We do not have time to clean this unit."

An interview was conducted with Staff #E5 after 2:30 PM on 9/26/2022. Staff #E5 was asked who was responsible for cleaning the Med Room. Staff #E5 replied, "Housekeeping does that, but we have to stay with them while they do it. They do not have a schedule to clean the med rooms and sometimes when they are on the unit cleaning, we don't have the time to stand there with them for it to be cleaned."

An interview was conducted in the afternoon on 9/28/2022 with Staff #E7. Staff #E7 was asked how she was informed of any incidents or complaints from the facility regarding the housekeeping staff. Staff #E7 stated, "I stay in touch with the Department Manager and he has not brought any concerns to me. We are contracted by the facility to provide all housekeeping services throughout the entire building." Staff #E7 confirmed there had been no reported incidents or complaints from the facility. Multiple pictures were shown to Staff #E7 of the findings during the facility tour.

During an interview on the morning of 9/29/2022 in the Administrative Conference Room Staff #E7 stated, "Those toilets were unacceptable."

Staff #E1, #E4, #E5, and #E7 confirmed the findings.


32143


Findings:
A tour was conducted of Unit 4 (Geriatric Unit) on 9-26-22 at 11:45 AM. The following items were found.

Room 402 A&B

had soiled floors. Paper, hair, and dust build up with a sticky substance on the floor.

The air conditioning units had a metal cover over the units for safety in each room. The bottom of the covers was attached to the floor. The cover was heavily soiled with dust, dirt, and hair. The covers had multiple holes all over the cover to allow air out and for return air. The holes were impregnated with heavy dust. Staff #D5 was shown the units and she was asked how often the units are cleaned. Staff #D5 stated that she did not know but would find out.

The bathroom was soiled on the floor and had a back/greenish moldy like substance on the inside of the toilet handle. There was dried urine on and around the base of the toilet. The toilet base that meets the tank was soiled with urine and a buildup of dust and hair.

The railing on the wall in the bathroom was soiled with a dried brown substance.

Room 404 A&B

had soiled floors. Paper, hair, and dust build up. The air conditioning units had a metal cover over the units for safety in each room. The bottom of the covers was attached to the floor. The cover was heavily soiled with dust, dirt, and hair. The covers had multiple holes all over the cover to allow air out and for return air. The holes were impregnated with heavy dust.

The bathroom was soiled on the floor and had a back/greenish moldy like substance on the inside of the toilet handle. There was dried urine on and around the base of the toilet. The toilet base that meets the tank was soiled with urine and a buildup of dust and hair.

Unit 4 Hallway

Paper and trash were found in the wall guards on the Geriatric unit.

Unit 4 Nurses Station Medication Room

The refrigerator in the Unit 4 medication room was found to have ice buildup in the freezer. Unable to be cleaned properly.

Unit 4 Seclusion Room

The seclusion room was soiled on the floors and bedding. The floors were dirty with dust, hair, paper trash, and food crumbs. Crumbs of food were found all over the bed spread.

Nurses Station
The floors were heavily soiled with dust and particles of paper, trash and hair. The air conditioner unit was a wall unit. The filter was heavily soiled with large chunks of sheet rock, dirt, and large amount of dust.


Unit 7 Adolescents

Room 17 on the unit revealed 2 patients were in the room during quite time. The floors were soiled with dust and bits of white particles. An interview was conducted with Patient #D7 and #D8 on 9/26/22 in the afternoon. Patient #D8 stated that when they came to the facility the bathroom was "very dirty. We didn't even want to use it." Patient #D7 stated that she asked the nurse for a bar of soap and a wash rag so they could clean their bathroom. Patient #D7 and #D8 complained that the facility was not very clean and they just clean their own room everyday. Both patients stated that eventually the housekeeper comes in and does a quick wet mop.


An interview was conducted with Plant OPS/Safety Officer during the tour on 9/26/22. He was asked about a schedule for the units and what staff cleaned what areas. The safety officer stated that he did not have a schedule. He was unable to verbally or physically show me who was responsible for what unit. The safety officer was asked if there was an issue and something needed to be cleaned, how would the staff communicate with housekeeping? The safety office stated they send out a text and communications are done all by texting. He was unable to tell me any schedules, who was responsible at the facility, and no other way to communicate other than text. The safety officer did state that this was a contracted services and Staff #D15 was the director from the contracted service.

Based on document review and interview the facility failed to ensure that a Medical History and Physical Examination with a neurological exam was completed in a timely manner in 1 (Patient #E4) of 3 medical records reviewed.

Findings:

PATIENT #E4
A review of the medical record revealed there was no History and Physical Exam/Neurological Exam documented in the medical record of Patient #E4.
Further review revealed Patient #E4 had a past medical history of Hypothyroidism and a Defibrillator/Pacemaker placement for cardiovascular disease.
A telephone order was given by Physician #E11 on 7/21/2022 at 12:30 PM for a History and Physical Consult to be completed.

During an interview with Staff #E11 on 9/28/2022 after 12:00 PM Staff #E11 confirmed that Patient #E4 was only seen by a psychiatrist until 8/20/2022. Physician #E12 examined the patient on 8/20/2022 at 10:35 AM for a right wrist fracture.
Staff #E12 confirmed the findings.

Based on document review and interview the facility failed to ensure that a Psychiatric Evaluation was completed in a timely manner in 1 (Patient #E4) of 3 medical records reviewed.

Findings:

PATIENT #E4
A review of the medical record revealed Physician #E10 gave a telephone order on 7/21/2022 at 12:30 PM to admit Patient #E4 for inpatient services. The Psychiatric Evaluation was not completed until 7/29/2022 at 4:11 PM by Physician #E10. This was greater than 60 hours after admission.
However, a progress note was written by Physician #E13 at 3:20 PM. This was 50 hours and 50 minutes after the patient was admitted to the facility.
During an interview with Staff #E11 on 9/28/2022 after 12:00 PM the findings were confirmed.

Based on an interview and a review of facility documentation, the hospital failed to ensure that there was an adequate number of registered nurses, licensed vocational nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program, as 2 of 5 units were not staffed according to the facility staffing plan.

Findings were:

Staffing for the facility's 5 units was reviewed for day shift on 9-27-22. Findings were as follows:
o Unit 4 (geriatric psych) - Unit was staffed with 1 RN and 1 LVN, although the staffing grid called for 2 RNs
o Unit 5 (Psychiatric ICU) - Staffed appropriately according to staffing grid
o Unit 6 (females) - Staffed appropriately according to staffing grid
o Unit 7 (adolescent) - Staffed appropriately according to staffing grid
o Unit 8 (dual diagnosis) - Unit was staffed with 1 RN and 1 LVN, although the staffing grid called for 2 RNs

The above was confirmed in an interview with the Chief Nursing Officer on 9-27-22.